FLAT FEET – PES PLANUS

What exactly is a “flat foot”?

When you stand, most people have a “space” under the arch or instep of the foot, however the depth of space under the arch can be variable. You may notice in young children that their feet often look a little flat, this is usually totally normal as the arch tends to develop in their feet by of 9 or 10 years old.

Is it normal? 

In many people if the flat foot has been present since teenage years it may simply be the way their foot is shaped and entirely normal. In these cases both feet are often the same. There are many “foot specialists” who may tell you that your arches have “fallen”. It is important that any such advice is given to you by a suitably qualified professional who can tell what is normal from abnormal. Having a longstanding flat foot can be ok.

How do I know if my flat foot is normal or abnormal?

If only one foot is affected it may be abnormal. If your foot is painful and you think it is flat then it is possible you have something causing the flat foot. People often complain of this discomfort on exercise. If your foot shape changes over time (months) i.e. if you had normal arches and then the foot flattens then there is likely an abnormality. Rarely, from childhood you may have had quite a stiff foot, which as you develop into adulthood can become increasingly painful. This could be an abnormally flat foot. 

How do I know whether my flat feet are a problem?

You should see your family doctor and ask for a referral to a foot and ankle specialist if:

  • you are in pain (even if it is a small amount of pain). It is important to remember that flat feet can cause pain elsewhere in your body, due to poor gait and your weight being loaded unevenly up through your body with each step. If you have flat feet and are experiencing knee pain, back pain or headaches, it is important to consider whether your foot structure is contributing to pain.
  • your foot feels stiff or hypermobile;
  • you wear out shoes very quickly;
  • your feet seem weak.

 

What causes abnormally Flat Feet? 

  • Tarsal coalition, a childhood condition that is an abnormal fusing of some foot bones which makes the foot stiffer and quite flat
  • Tibialis posterior Tendon dysfunction. This is a large ankle tendon that can degenerate causing it to stretch and cease working correctly. It can be unexplained in many patients, in others it can be a build up of minor injuries.
  • Excessive laxity in the joints and this can be related to weight gain
  • Foot arthritis, arthritis in the back or middle of the foot is usually painful. It can be caused by an injury or develop with no real explanation.

What are the symptoms?

People may find walking painful especially along the inside border of the foot and ankle. Running can be very difficult due to pain. They can also get swelling in the inside of the ankle. Sometimes tingling or numbness can develop on the inside or sole of the foot because the nerve along the inside of the ankle may be slightly stretched or compressed.

How is the condition diagnosed?

The diagnosis is based on an accurate history or story of symptoms from the patient. Examining the foot for pain and swelling can differentiate a normal and abnormal flat foot. X-Rays can display the overall shape of the flat foot. They can also diagnose arthritis as a feature of the flat foot. An MRI scan is useful to determine whether the tendon is working normally and also if there are any abnormal bony fusions.

Can the problem get worse?

Unfortunately yes it can. If the cause is a simple tendon abnormality causing the foot to flatten then it can be helped with insoles and physiotherapy as the arch can be restored fairly easily. If the foot is left untreated then the foot can become arthritic and the flat foot can be quite stiff and impossible to correct with insoles. It is vital to get assessed as soon as possible as solutions to your problem can change a lot and become more difficult over time.

Different stages of flat feet

Problems related to flat feet are classified into different stages and these stages define what sort of treatment can be carried out.

Stage one

There is inflammation of the tendon but no obvious deformity. Diagnosis is made during a physical examination and confirmed by ultrasound or MRI.

Stage two

The severity of the flat foot is increasingly evident but it is not stiff or arthritic.

Stage three

The condition is increasingly painful and has lead to stiffness and arthritis in the hind foot.

Stage four

The arthritis has spread to the ankle joint.

 

How do you treat Flat feet?

If the foot is flat but flexible then you may be able to have treatment with simple insoles and physiotherapy. The idea is to support your foot to stop it getting worse but unfortunately the arch would be permanently flat without the insoles. For a more active person this treatment may not be satisfactory. In this case surgery to re-create the arch can be performed, a flat foot correction.

Will I need surgery for flat feet?

Surgery is sometimes required if the condition is more severe. The following procedures may be considered:

The calcaneal osteotomy

Sometimes known as the ‘heel shift’, this procedure involves moving the calcaneam, the large bone at the back of the heel which is out of alignment, correctly re- positioning it and then securing the bone using screws. At LFAC, we can sometimes, where appropriate, carry out this procedure in a minimally invasive way.

A tendon transfer

This is considered if the tibialis posterior tendon is severely damaged. A tendon is taken from one of the lesser toes, which is then transferred to run behind the medial malleolus. This does not affect the function of the toes and patients make a full recovery.

Fusion

At the final stages (stage 3 and stage 4) of adult flat foot, the fusion of joints needs to be considered in order to effectively eliminate pain.

Deciding whether surgery is necessary

Many patients are simply seeking advice on managing a problem. If you have an abnormal flat foot it will never be made “a normal shape in a normal shoe” without surgery. You can manage it with special insoles and physiotherapy but it can still get worse. Specially made shoes can be an attractive option, if your lifestyle is less active than others. Surgery is successful in over 80% of patients and worth discussing with your surgeon.

FLAT FEET – PES PLANUS Treatment at Udai Omni Hospital flat feet Treatment at Udai Omni Hospital

Achilles Tendonitis

Tendonitis is a term which means inflammation or swelling, and it occurs often in and around the Achilles.

There are two areas of the Achilles prone to this problem: in the middle of the tendon (mid-substance Achilles tendonitis) and at its insertion into the heel bone (Insertional Achilles tendonitis).

Patients with tendonitis within the heel and Achilles, may be seen in our Heel Pain Clinic where they can normally have an assessment, imaging, decision and first treatment within a single, first clinic visit.

Where is the Achilles tendon?

The Achilles tendon is the large, strong tendon that connects the calf muscles, specifically the gastrocnemius and soleus muscles to the heel bone or calcaneum. It allows you to point your foot downwards and push off the ground when you are walking or running.

   

What causes Achilles tendon pain?

  • In many patients no definite cause is found.
  • The Achilles tendon can withstand huge forces even in people who are recurrently stressing it, such as in long distance running however despite good conditioning, pain can ensue.
  • Rapid increases or changes in training regimes can precipitate the symptoms.
  • Inappropriate shoe-wear that can alter the mechanics of your foot when you hit the ground whilst running can increase symptoms.
  • Patients with more general symptoms such as that associated with different types of arthritis/inflammatory disorders can develop Achilles pain. 

Why does it get painful?

The tendon is made up of strong fibres made of collagen. Over time this substance can “degenerate” and become weaker and less flexible. As this occurs then tiny microscopic tears can develop in the tendon, leading to weakness, pain and eventually swelling. The tendon swelling often develops in the middle of the tendon because this area has a less well-developed blood supply hence unable to heal itself effectively.

What are the symptoms?

  • Pain and stiffness along the Achilles tendon in the morning
  • Pain along the tendon or back of the heel that worsens with activity
  • Swelling that is present all the time and can get worse throughout the day with activity
  • Severe pain the day after exercising
  • Thickening of the tendon

Achilles tendinopathy (non-insertional)

When pain, weakness and loss of function is associated with a swelling in the main portion of the tendon and not down at the bottom by the heel bone, it is referred to as Achilles tendinopathy. “Tendinopathy” is used to describe the typical microscopic findings in this condition and means tissue degeneration in the tendon fibres.

Achilles tendinopathy (insertional)

When pain, weakness and loss of function is associated with a swelling down at the bottom of the tendon by the heel bone, it is referred to as insertional Achilles tendinopathy. This is because the tendon “inserts” onto the heel bone. Sometimes the heel bone can be quite prominent here and very painful. This can be because of a combination of problems here including: 

  • Achilles tendon degeneration
  • Bone spurs at the tendon insertion

Inflammation of a small bursa (fluid filled sac behind tendon) – bursitis

How is the condition diagnosed?

The clinical features usually diagnose the problem. An X-Ray can be done to look for tissue swelling or bone spurs. A more helpful test is an ultrasound which can easily be done to look at the tendon quality or an MRI.

Can the problem get worse?

People often “live” with the symptoms for quite a while, or alter their activity profile. The symptoms can, unfortunately, progress with a potential even for rupture of the tendon. It is advisable getting assessed by a foot and ankle surgeon or physiotherapist when possible.

How do you treat Achilles tendinopathy?

Both insertional and non-insertional tendinopathy can be treated in a similar fashion.

The treatment is operative or non-operative.

The vast majority of patients require no surgery. Activity modification and rest coupled with suitable anti-inflammatories or pain-killers can really make a difference. Early rest in a boot may be needed in the short-term. A small heel raise (silicone insert) can help in the shoe. It is important to get introduced to a correct physiotherapy regime as they can prove hugely successful IF FOLLOWED AS INSTRUCTED. If physiotherapy is not fully successful then shock wave therapy can be used which has good results.

Operative treatment can be performed if other measures fail. Surgery usually involves exploration of the painful tendon area and removal of the degenerate/inflamed tissue or painful bony bumps on the heel. If the tendon is detached from the bone during surgery or a large amount of the tendon is removed then using another tendon in the foot to support the damaged Achilles tendon may be needed. This is not usually needed

 

Anirudh Krishnan

I, Anirudh Krishnan, am studying in Good Shepherd International School, Ooty. In Sep 2014, when I was 11yrs old (7th grade), my world came crashing down. I had a numbing pain in my legs and couldn’t walk! My movements were restricted and I had to be taken back home for treatment. The journey from Ooty to Coimbatore and the flight to Hyderabad were agonizing. I was in grief and kept weeping in pain. Over the next 10 days, after many rounds of hospitals, MRI’s, scan’s and a whole lot of other tests; we were informed that I had SCFE (Slipped Capital Femoral Epiphysis).

I was admitted to Udai Omni Hospital and Dr. Udai Prakash carried out further tests. He advised that SCFE was a fracture through the growth plate which was causing me pain whenever I walked or ran. He patiently educated that the remedy is to insert 2 screws (one on each hip) to fix the femur and the growth plate. I was so frightened and started weeping. I was operated on 11 Sep 2014 and Dr. Udai Prakash and his team coached me on physiotherapy and how to deal with my pain.

I came back home on a stretcher and was bedridden for nearly 3 months. Physiotherapy and watching TV became my only hobbies. I used to spend so many sleepless nights dreaming that I will never be able to walk normally again. Gradually my strength came back and my legs got stronger. I was able to walk baby steps with the aid of crutches. Meanwhile, I had missed a whole School term. I returned back to School in 2ndterm but couldn’t participate in any activities for another 3 months.

I was re-operated in Dec 16 to remove the screws. Over the past 3 years, I have got back to normal, and even won a few medals in sports for swimming and running. Ironically, I had never won a medal when my legs were normal and the journey has only made me stronger.

I even gave a talk to my friends about how to overcome pain and continue to work hard. These days, I motivate everyone that if I can overcome so many problems despite having screws in my legs, they should strive to achieve much better and not cry over small failures.

I am grateful to Dr. Udai Prakash for his constant care and encouragement. Dr. Udai Prakash has been so supportive through the past 3 years and I trust him a lot. I am happy to be normal again and enjoy water sports and all other sporting activities.

Dr Raghava at Brazil for BRICS Meeting April 2017

BRICS (Brazil,Russia,India,China,South Africa) countries will be meeting for the very first time in Rio De Janerio from 20th to 23rd of April 2017. Dr.Raghav Dutt will represent India as the President of ASSI- Association of Spine Surgeons of India. He will be delivering a lecture on “Growth modulation problems of growth rods and bi convex fusion” to spine surgeons from the leading countries. This is a mega spine conference to be attended by a huge galaxy of spine surgeons from BRICS countries.

Udai Omni Hospital is proud that its Director and Chief of Spine Surgery represented our country in this august gathering of Spine Surgeons,

Dr Raghav​a​ Dutt Mulukutla is President of ​Association of Spine Surgeons of India (​ASSI​)​ 2017-19

​Dr Raghava Dutt Mulukutla, Director Udai Omni Hospital has been appointed President of ASSOCIATION OF SPINE SURGEONS OF INDIA (ASSI), the largest association of ​spine surgeons in India with a membership of about 1500 spine surgeons from all over India.

ASSI collaborates with spine organisations world wide to spread safe spine surgery and is dedicated to the advancement of spine surgery and patient care.

​In its endeavor to promote research and better practices in spine surgery, ASSI ​conducts conferences, ​offers ​accredited ​educational opportunities​, ​clinical fellowships at reputed spine centers​, opportunities for both clinical and research work in sub specialties of spine trauma, spine deformities, degenerative and cervical spine issues to spine surgeons.

We at Udai Omni Hospital are extremely proud of Dr Raghava Dutt Mulukutla’s accomplishments and congratulate him on his newest honour.

 

Dr Raghav​a​ Dutt Mulukutla is President of ​Association of Spine Surgeons of India (​ASSI​)​ 2017-19

​Dr Raghava Dutt Mulukutla, Director Udai Omni Hospital has been appointed President of ASSOCIATION OF SPINE SURGEONS OF INDIA (ASSI), the largest association of ​spine surgeons in India with a membership of about 1500 spine surgeons from all over India.

ASSI collaborates with spine organisations world wide to spread safe spine surgery and is dedicated to the advancement of spine surgery and patient care.

​In its endeavor to promote research and better practices in spine surgery, ASSI ​conducts conferences, ​offers ​accredited ​educational opportunities​, ​clinical fellowships at reputed spine centers​, opportunities for both clinical and research work in sub specialties of spine trauma, spine deformities, degenerative and cervical spine issues to spine surgeons.

We at Udai Omni Hospital are extremely proud of Dr Raghava Dutt Mulukutla’s accomplishments and congratulate him on his newest honour.

 

UDAI OMNI recognizes the talent in this young star – Ms. Poorvi Singh

 

As a mark of support, Directors of Udai Omni – Dr. Raghava Dutt Mulukutla, Dr. Udai Prakash, Mr. Surya Reddy Pulagam, and Mr. Ranjit K, CEO present her with a token of appreciation.

Ms. Poorvi Singh is presently a student of Villa Marie College. She started her Badminton Career in 2012, at a summer camp held at Lal Bahadur Stadium. Her then coach tapped her potential and egged her to carry on playing the sport. Since childhood, she has been very focused and dedicated. During practice in the morning, they would do fitness exercises and in the evening, court practice for 2-3 hours daily.

She won her first award, at Hyderabad District School Games Federation in 2012-13, coming 1st, which motivated her and also lead her to many more wins at District levels.

Poorvi always stood at the top 16 at National Level in Telangana State in Junior Championships held at Warangal, Nizamabad, and Karimnagar to name a few. She participated in the State level Women’s Sports competition under Rajiv Gandhi Khel Abhiyan for the year 2015-16 and she came third.

The hospital had treated Poorvi for spine issues related to sports injuries a few years back and today, thanks to the expert treatment and medical care at UDAI OMNI, under the guidance of Dr. Raghava Dutt Mulukutla, Poorvi is not only playing the game, she is on the way to winning laurels.

 

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